LIPIDS/LIPOPROTEINS: TOTAL LIFESTYLE CHANGESThe recommendations for TLC changes also are now similar from the two groups. The essential features of TLC, as defined by NCEP (ATIII), are as follows:• Reduced intakes of saturated fats (< 7% of total calories) and cholesterol (< 200 mg/day)• Therapeutic options for enhancing LDL-lowering, such as plant stanols/sterols (2 gm/day) and increased viscous (soluble) fiber (10-25 gm/day)• Weight reduction• Increased physical activityThe nutrient composition of the TLC diet differs only slightly from the nutrition plan recommended by the ADA. In particular, total fat may range from 25% to 35%, particularly if saturated fats and trans fatty acids are kept very low. The ADA recommends that fat intake be < 30% but acknowledges that monounsaturated fat may be substituted for carbohydrates. The focus is on patients with high plasma triglyceride and low HDL-C levels, a problem which has been recognized for over 25 years in type 2 diabetes.The ATP III report recommends that TLCs should be prescribed, with a vigorous emphasis on weight reduction and physical activity. Plasma f LDL-C level should be lowered to ^ 100 mg/dl. If TLC is not effective in, 3-6 months, drug therapy is needed to lower LDL-C to the target of < 100 mg/dl. For high triglyceride levels (200^199 mg/dl) after these steps have been taken, non-HDL-C is recommended as a therapeutic target. The non-HDL-C goal is 30 mg/dl higher than the LDL-C goal. Non-HDL-C is obtained simply by subtracting the plasma level of HDL-C from the total cholesterol. Elevation > 130 mg/dl suggests elevation of LDL-C, and fi-brate or nicotinic acid therapy is considered. In the case of an isolated low HDL-C levels in a diabetic, therapy with fibrates is recommended.*169\357\8*

• are a small-framed female,

• have a small appetite,

• do very little physical activity,

• are trying to lose weight.

Even the smallest eater needs these carbohydrate foods every day:

• around 4 slices of bread or the equivalent (crackers, rolls, English style muffins)

PLUS

• at least 2 pieces of fruit or the equivalent (juice, dried fruit) PLUS

• about 1 cup of high carbohydrate cooked vegetables (corn, legumes, potato, sweet potato)

PLUS

• about 1 cup of cereal or grain food (breakfast cereal, cooked rice or pasta, or other grains)

PLUS

• at least 1 Vi cups of low-fat milk or the equivalent (yoghurt, ice cream). This includes milk in your tea and coffee and with your cereal.

If this amount of food sounds right for you, try it as a minimum amount of carbohydrate. This supplies 175 grams of carbohydrate, suitable for a 5000 kilojoule (1200 Calorie) diet.

Listen to your appetite if it demands more.

How could you change your diet? Some of the most common changes that people tell us they have made to their diet using the G.I. factor are:

• Eating grainy breads.

• Eating more fruit and yoghurt.

• Eating lots of pasta, beans and vegetables.

*17\33\4*

It is often very difficult to distinguish between an ordinary 2-year-old tantrum or a normal expression of developing independence and an insulin hypo. You will learn with experience and observation but you should do a blood test if in doubt, but if this is inconvenient you can be guided a little by a number of factors. Firstly, what time of the day is it?

If it is just before a meal or at a time when your child’s particular insulin is having its maximum effect, then it is more likely to be a hypo. If your child is sweaty and pale then once again it is more likely to be an insulin reaction. On the other hand, if something has happened which might reasonably lead to a tantrum or expression of bad temper, then you might find it a better course to ignore it rather than to play into his own hands by making a fuss over him. Certainly there will be times when you are not sure, and on such occasions it is probably better to treat it as a hypo and see the effect of giving an exchange of sugar. If he starts to improve soon after giving sugar, then it was very possibly an insulin reaction. It may be wise not to use too attractive a form of sugar in these situations (for instance, a compressed glucose tablet might be better than a barley sugar or lemonade) for fear that your child might ‘put on a turn’ in order to be rewarded with sugar.

*83/54/5*

1.     Plenty of syringes – allow for unscheduled delays.

2.     Swabs – the individual packs are convenient.

3.     Plenty of insulin – extra bottles for breakage or loss and a bottle of quick acting insulin even if your child is not using it regularly.

4.     Plenty of blood testing strips for your meter.

5.     Supply of blood testing strips which can be used without the meter, such as Glucostix or BM Test Glycemie 20-800. These are useful if the meter breaks down or if it is inconvenient to use it.

6.     Blood glucose meter.

7.     Tests for ketones in urine (Ketodiastix or Ketodiabur).

8.     Glucagon kit.

9.     Glucose in some form – for example, barley sugar.

10.     A letter from your doctor about your child as an introduction to a doctor or hospital if you need help while away.

11.     A letter for Customs officials if you are travelling overseas. The doctor will certify that you need to carry insulin and syringes.

12.     Identification of your child clearly indicating that he or she has diabetes and is on insulin treatment.

13.     Some snacks while travelling in case meals are delayed.

14.     Travel alarm clock.

Insulin adjustment

Short journeys or travelling within the same general time zone (for example between Australia and Hong Kong) pose no problems. Give insulin and meals close to the usual time. If you cross a time zone, keep one watch on the home time and give snacks at the usual time to prevent hypoglycemia.

For long journeys to a different time zone (for example Australia to England or America) some advanced planning is required. Ask the travel agent to get a flight schedule for the journey for you expressed in both local time and in the time of the city from where you set out for the journey. You can then discuss this with your doctor or clinic.

If you are on two injections a day, this is easy. You may need to vary the morning and evening dose so that when you reach your destination, the insulin fits naturally into your new time scale.

If you are on one injection a day, you should discuss this with your doctor. Usually it is better to give half doses at about twelve hourly intervals during travel and then the usual dose before breakfast when you arrive.

Meals

In general it is usually easier if you:

1. Keep one watch on the home time (the time in the city where you started the journey), judging meal times by this.

2. Try to use airline meals. There is usually plenty of carbohydrate, but you may ask in advance for fruit or extra bread to make up carbohydrate allowance. Some airlines provide’ suitable meals for persons with diabetes on request. Check with your travel agent.

3. Keep an eye on your home time watch. It will tell you when it is time for a snack. Take some snacks with you. Airlines are usually very helpful in providing extra food or serving you first if you ask in advance.

Blood tests

Do blood tests from time to time. It is reassuring to know you can prevent hypoglycemia this way. Don’t worry if the tests are a bit high: they probably will be, because of the inactivity of sitting for long distances. You can use blood strips that don’t require a meter.

Exercise

Take the chance to walk around at transit airport stops. It breaks boredom, provides useful exercise, and helps prevent swollen ankles.

*73/54/5*